Monday, August 22, 2016

Children with congenital Zika virus infection could have an array of difficulties and will need careful evaluation and follow-up, according to federal health officials.

The Centers for Disease Control and Prevention (CDC) has released crucial new guidance for pediatricians and other pediatric clinicians that was developed in consultation with the Academy and other experts.

"We felt there was an urgent need to develop guidance for pediatric health care providers on how to evaluate and manage babies born with congenital Zika virus infection (in order) to give those kids the best chance to reach their full potential," said co-author Sonja A. Rasmussen, M.D., M.S., FAAP, a pediatrician and clinical geneticist at the CDC.

The report "Update: Interim Guidance for the Evaluation and Management of Infants with Possible Congenital Zika Virus Infection – United States, August 2016" was published Friday in the Morbidity and Mortality Weekly Report.

This guidance comes just one week after the U.S. declared a public health emergency in Puerto Rico where 10,690 people have become infected with the mosquito-borne virus including 1,035 pregnant women, according to the U.S. Department of Health and Human Services. In U.S. states, 2,260 cases have been reported, including 529 pregnant women, according to the CDC.

Experts from around the country gathered at the CDCin July to discuss how to evaluate and care for infants with congenital Zika virus infection, which can causemicrocephaly and other issues such as vision and hearing difficulties, contractures and developmental delay.

"Developmental screening and expeditious referral to early intervention when indicated are critical," said Fan Tait, M.D., FAAP, AAP associate executive director and director of the Department of Child Health and Wellness. "Following the diagnosis, families will need both emotional and psychosocial support."

The new guidance calls for all infants whose mothers were infected with Zika during pregnancy to have a comprehensive physical exam, neurologic assessment, postnatal cranial ultrasound, standard hearing screen and Zika testing.

Babies who are found to be infected also should have a comprehensive eye exam and hearing assessment by auditory brainstem response testing before 1 month of age regardless of whether abnormalities are apparent at birth.

If abnormalities are detected, infants will need to be evaluated by an infectious disease specialist, neurologist, endocrinologist, ophthalmologist and geneticist. The primary care pediatrician and these specialists will need to provide coordinated ongoing examinations that are detailed in the guidance.

"We really emphasized in this guidance some of the ... AAP tenets that these babies need a medical home, they need someone to help them coordinate their care," Dr. Rasmussen said.

Those who are not born with obvious, identifiable abnormalities will need careful monitoring for any that may present later in life such as those resulting in seizures or troubles with vision or hearing.

"It's going to be important to follow those children for neurodevelopmental abnormalities as they would any child but probably with just more focused attention on the potential for developmental regression or development delays," said Edwin Trevathan, M.D., M.P.H., FAAP, a member of the AAP Section on Neurology and a pediatric neurologist at Vanderbilt University Medical Center.

The CDC continues to encourage women with Zika infection to breastfeed their infants, saying the benefits outweigh any possible risks. The agency will continue to update guidance on caring for infants as experts learn more, and Dr. Trevathan emphasized the importance of pediatricians staying up to date.

"I think we will be better off as a pediatric community and our children will be better for it," he said.

It is also available at Kenyatta National Hospital, Armed Forces Memorial Hospital and at health facilities operated by county health authorities and at county headquarters in Nairobi, Mombasa, Kisumu and Eldoret.

This comes as an emergency vaccination programme is under way in DR Congo, targeting three million people in a desperate move to curb the spread of the disease caused by the same mosquito that causes Zika, Aedes Egypti.

The first yellow fever cases were detected in Luanda, Angola, late last December and were confirmed by the National Institute for Communicable Diseases in South Africa on January 19, 2016 and by the Institut Pasteur Dakar on January 20.

The DRC has reported 1,798 suspected and 68 confirmed cases with 85 reported deaths as at June 24.

In Angola, the Health ministry reported 3,625 suspected cases from December 5, 2015 to July 8, 2016, of which 876 were laboratory confirmed. The number of reported deaths is 357, of which 117 were among confirmed cases.

What is worrying is that there is persistent local transmission in the country despite approximately 15 million people having been vaccinated.

Save the Children, a British charity, has warned that a yellow fever outbreak — currently the largest global one in three decades — in the Democratic Republic of Congo and Angola could soon spread to Europe, the Americas and Asia.

Kenya and the People’s Republic of China reported two and 11 cases respectively, all imported from Angola.

(CNN)Angola and the Democratic Republic of Congo began an emergency vaccination campaign this week to curtail a yellow fever outbreak that has sickened thousands of people and killed more than 400, the World Health Organization said. The two countries, which together reported more than 6,136 suspected cases and 953 confirmed cases since the outbreak began in December, plan to vaccinate more than 14 million people in more than 8,000 locations.

Emergency measures using just one-fifth the standard dose will be implemented in order to reach as many people as possible. This "fractional dosing" method was recommended by an advisory group of experts as the best way to maximize the limited supply of vaccines, which require at least six months to manufacture. The WHO approved 21 million vaccine doses for Angola and 11.5 million doses for Congo.

Yellow fever is a viral hemorrhagic disease transmitted by infected mosquitoes. Symptoms include fever, headache, jaundice, muscle pain, nausea, vomiting and fatigue. A small proportion of patients develop severe symptoms, and nearly half of these die within 10 days.

How many people are sick?

In Angola, the outbreak began in late December in the capital city, Luanda, and spread to 16 of the country's 18 provinces. As of August 4, the date of the most recent report for the country, a total of 3,867 suspected cases have been recorded, though only 879 of these cases have been laboratory confirmed. Though deaths now number 369, no new cases have been confirmed during July and early August. To prevent any renewed outbreaks, the Angola vaccination program began on Monday.

In Congo, the outbreak was declared on April 23, with health officials reporting a total of 2,269 suspected cases and 74 confirmed as of August 8, the most recent reporting date for the country. Seven of the country's 26 provinces have confirmed cases, and 56 of these are known to have been imported from Angola. The health ministry scheduled the vaccination campaign to begin Wednesday, focusing first on the capital province of Kinshasa and border areas with Angola.

Two million of Kinshasa's 10 million residents have been vaccinated, according to the WHO, and more than 16 million people have been vaccinated in Congo and Angola combined.

Rolling out a massive vaccination campaign

The virus is endemic in tropical areas of 47 countries in Africa and Central and South America. Since 2006, more than 105 million people have been vaccinated in mass campaigns.

Usually, the planning stage of an emergency vaccination campaign can take between three and six months. However, even though the current campaign is one of the largest ever attempted in Africa, it must begin as soon as possible to end transmission before the rainy season in September.

The time crunch is necessary to get ahead of the peak transmission season that follows the rain, according to Dawn Wesson, associate professor of the vector-borne infectious diseases initiative at Tulane University School of Public Health and Tropical Medicine. "Basically the rainy season creates many, many, many more breeding spots, which leads to more mosquitoes and more disease transmission," she said.

According to the WHO, some areas also become inaccessible during the rainy season.

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To accomplish the emergency vaccination campaign, the health ministries in Angola and the Congo and the WHO are coordinating with 56 global partners, including Médecins sans Frontières, the International Federation of the Red Cross and UNICEF. Approximately 41,000 health workers and volunteers are needed for the campaign, the WHO noted. Supplies include 500 vehicles and 17.3 million syringes.

Monday, August 1, 2016

For much of the past year, the Zika virus has dominated the news cycle and commanded international attention. But another mosquito-borne disease, yellow fever, is working its way (albeit more quietly) through the African nations of Angola and the Democratic Republic of the Congo. Though it has attracted far less attention than the Zika virus, yellow fever nevertheless could disrupt economic activities in and beyond those countries, a key consideration in assessing the geopolitical risk of a disease outbreak. What's more, a large number of foreign workers in Angola and the Congo as well as a vaccine shortage worldwide could conspire to turn the latest outbreak of yellow fever — a disease that has been preventable for nearly 80 years — into a more global concern.

Angola's latest outbreak of yellow fever began in December 2015. Since peaking in early 2016, the incidence of new cases has dropped off. But that does not mean the outbreak is under control. Containing the spread of the disease remains an issue; though about 70 percent of Angola's population (around 15 million people) has been vaccinated against yellow fever, transmission continues. Furthermore, as recently as May, incidences of the disease were popping up in regions previously unaffected by the epidemic. In neighboring Congo, the outbreak is still developing. Having crossed the porous border with Angola, the disease has already reached five Congolese provinces, causing nearly 2,000 suspected cases.

Angola's economic ties with China could also prove to be a conduit for transmitting yellow fever. Angola sends roughly half its crude oil exports to China, and Chinese direct investment, in turn, has buoyed not only Angola's oil sector but also its construction industry. Along with the money, hundreds of thousands of Chinese citizens have gone to Angola for work; more than 250,000 resided there in 2012. Similarly, China has invested a substantial amount of money and manpower into mining projects in the Congo, where at least 5,000 Chinese workers live. Considering the size of the population overlap, it is not at all surprising that China reported 11 confirmed cases of yellow fever from Angola in April. As the disease continues to spread in Angola and the Congo, more cases could be brought back to China. So long as Angola's oil production and the Congo's mining activities continue as expected, yellow fever's effect on the global economy should be minimal. But given the limited supply of yellow fever vaccine, if the disease takes hold in China, it could have wider economic consequences.

Comment: Given the large number of Indians who are traveling to Africa for work and VFR (visiting friends and relatives) it would be prudent to ensure that proper Yellow Fever Vaccination is taken and certification done for all Indian travelers. Otherwise, we may end up with yellow fever epidemic in India as well.

About Me

I am a pediatrician based at Mohali, a suburb of chandigarh, North India. I have my own virtual office at www.charakclinics.com; I have been a pediatrician since 1994. I hope to make ths blog a regular feature with tonnes of relevant info for parents, especially in India, because i feel that "informed parents are better parents". My interests include research in OPD practice, specifically new vaccines and travel medicine. I am a member of American Academy of Pediatrics, Indian Academy of Pediatrics, and various travel organizations like International Society for Travel Medicine (ISTM), American Society of Tropical Medicine & Hygiene (ASTMH), International Association for Medical Assistance to Travelers (IAMAT), and British & Global Travel Health Association (BGTHA)